Exam 45: Care of Critically Ill Patients with Neurologic Problems

A nurse assesses a client with the National Institutes of Health (NIH)Stroke Scale and determines the client's score to be 36.How should the nurse plan care for this client?

A client has a brain abscess and is receiving phenytoin (Dilantin).The spouse questions the use of the drug,saying the client does not have a seizure disorder.What response by the nurse is best?

A nurse is caring for four clients who might be brain dead.Which client would best meet the criteria to allow assessment of brain death?

A client has meningitis following brain surgery.What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

A client has a traumatic brain injury.The nurse assesses the following: pulse change from 82 to 60 beats/min,pulse pressure increase from 26 to 40 mm Hg,and respiratory irregularities.What action by the nurse takes priority?

A client with a stroke is being evaluated for fibrinolytic therapy.What information from the client or family is most important for the nurse to obtain?

A client has a traumatic brain injury and a positive halo sign.The client is in the intensive care unit,sedated and on a ventilator,and is in critical but stable condition.What collaborative problem takes priority at this time?

A nurse is working with many stroke clients.Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury.The client's spouse is very frustrated,stating that the client's personality has changed and the situation is intolerable.What action by the nurse is best?

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit.Which client should the nurse assess first?

A nurse is seeing many clients in the neurosurgical clinic.With which clients should the nurse plan to do more teaching? (Select all that apply.)

A client had an embolectomy for an arteriovenous malformation (AVM).The client is now reporting a severe headache and has vomited.What action by the nurse takes priority?

A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg.Based on the client's cerebral perfusion pressure,what should the nurse anticipate for this client?

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting.The client's mental status is deteriorating.What action by the nurse is most appropriate?

A client has a subarachnoid bolt.What action by the nurse is most important?

A client who had a severe traumatic brain injury is being discharged home,where the spouse will be a full-time caregiver.What statement by the spouse would lead the nurse to provide further education on home care?

A student nurse is preparing morning medications for a client who had a stroke.The student plans to hold the docusate sodium (Colace)because the client had a large stool earlier.What action by the supervising nurse is best?

The nurse is caring for four clients with traumatic brain injuries.Which client should the nurse assess first?

A client had an embolic stroke and is having an echocardiogram.When the client asks why the provider ordered "a test on my heart," how should the nurse respond?

A nurse cares for older clients who have traumatic brain injury.What should the nurse understand about this population? (Select all that apply.)